curve than other brow-lift procedures, mainly because of the use of endoscopes, cameras, and special instruments, its excellent and lasting results warrant its application.

References

1.Pitanguy I. Indications and treatment of frontal and glabellar wrinkles in an analysis of 404 consecutive cases of rhytidectomy. Plast Reconstr Surg. 1981;67:157–66.

2.Miller CC. Subcutaneous section of the facial muscles to eradicate expression lines. Am J Surg. 1907;21:235.

3.Gonzales-Ulloa M. The history of rhytidectomy. Aesthetic Plast Surg. 1980;4:1.

4.Core GB, Vasconez LO, Askren C, et al. Coronal facelift with endoscopic techniques. Plast Surg Forum. 1992;15:227.

5.Liang M, Narayanan K. Endoscopic ablation of the frontalis and corrugator muscles, a clinical study. Plast Surg Forum. 1992;15:58.

6.Isse N. Endoscopic forehead lift. Paper presented at the annual meeting of Los Angeles County Society of Plastic Surgeons; 1992.

7.Castanares S. Forehead wrinkles, glabellar frown and ptosis of the eyebrows. Plast Reconstr Surg. 1964;34:406.

8.McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg. 1991;15(2):141–7.

9.Zimbler MS, Nassif PS. Adjunctive applications for botulinum toxin in facial aesthetic surgery. Facial Plast Surg Clin North Am. 2003;11(4):477–82.

10.Nassif PS, Kokoska MS, Cooper P, et al. Comparison of subperiosteal vs subgaleal elevation techniques used in forehead lifts. Arch Otolaryngol Head Neck Surg. 1998;124(11): 1209–15.

11.De La Fuente A, Santamaria AB. Facial rejuvenation: a combined conventional and endoscopic assisted lift. Aesthetic Plast Surg. 1996;20:471–9.

12.Oslin B, Core GB, Vasconez LO. The biplanar endoscopically assisted forehead lift. Clin Plast Surg. 1995;22:633–8.

13.Holzapfel AM, Mangat DS. Endoscopic forehead-lift using a bioabsorbable fixation device. Arch Facial Plast Surg. 2004;6(4):389–93.

14.Stevens WG, Apfelberg DB, et al. The endotine: a new biodegradable fixation device for endoscopic forehead lifts. Aesthetic Surg J. 2003;23(4):103–7.

15.Larrabee WF, Makielski KH, Cupp C. Facelift anatomy. Facial Plast Surg Clin North Am. 1993;1:135–52.

16.Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. 1966;38:352–6.

17.Tardy ME, Thomas JR, Brown R. Facial aesthetic surgery. 1st ed. St. Louis: Mosby; 1995.

18.Sclafani AP, Fozo MS, Romo T, et al. Strength and histological characteristics of periosteal fixation to bone after elevation. Arch Facial Plast Surg. 2003;5(1):63–6.

Since his origin, man has possessed a sense of beauty that is innate and is accompanied by the desire to keep youthfulness and this has led him to look for different methods to get his objective of keeping himself beautiful and young.

The forehead is considered as a very important aesthetic unit in the facial appearance. The eyebrows, as well as the eyelids and the lips are expression signs that reveal the emotions, feelings, and state of mind and they accompany the person’s oral language. For being a mobile unit, it is here where the aging signs are most marked. In some occasions, the forehead crosswise wrinkles can be comparable to a scar.

We can see that in children or young patients, the eyebrow tail goes over the orbital flange. In advanced aged patients, this relation is reversed and it can be observed that a lower eyebrow tail than the eyebrow head is a sign of aging.

Aging with subsequent gradual eyebrow decrease and the changes in the forehead is attributed to different causes. Among them is age, the flaccidity occasioned by fat reabsorption, the mass loss, the muscular tone, and the three-dimensional loss of the bony volume. Also involved besides the mobility are the gravity effects on the tissues and the environment effects such as the sun, the wind, etc.

G.G.R. Duarte

Plastic and Reconstructive Surgeon, San Martín University, Cra. 18 No. 80-35, Bogotà D.C., Colombia, CES University, Calle 10 A No. 22 - 04, Medellín, Antioquia, Colombia and Cra 18 No. 85-36 Of. 201, Bogota, DC, Colombia

e-mail: contacto@germanrojas.com

Traditionally, facial rejuvenation surgical treatments were centered in the cheeks and neck. Nowadays, in the handling of the face it has become very important to get a harmonic balance of the facial contour by attempting to obtain a natural state.

The first description on forehead lifting was reported in 1919 by Lexer [1]. It consisted of lifting the skin and the muscles superiorly, cutting the skin excess, and suturing. In 1926, Noel [2] presented his frontal lift technique. In 1931, Joseph [3], considered as the father of the modern plastic surgery, proclaimed his technique of skin elliptic resection immediately above the hair implantation line. In 1926, Hunt [4] published his technique through frontal bone incision. In 1957, Edwars proposed to carry out selective neurotomies of the facial temporary line to produce a facial paralysis of the frontal muscle. In 1951, Fomón [5], through eyebrow incisions, proposed to carry out avulsion of the insertions of the corrugator, procerus, frontal, and orbicular muscles, performing resection of the facial nerve frontal line also.

In 1956, Ichi-Uchida [6] proposed to dry up skin beneath the hairy implantation line and frontal muscle resection. In 1962, González-Ulloa recommended to use a skin elliptic wedge beneath the hairy front implantation line with no skin dissection. In 1973, Marino published his frontal bone incision technique, following the McIndoe postulates, with skin dissection up to the orbital edge and partial resection of the front, procerus, and corrugator muscles. In the 1970s and 1980s, with the boom of the reconstruction surgical techniques of the cranial-facial surgery through frontal bone incisions and mobilization of big facial flaps with satisfactory results, the application of these techniques led to the aesthetic surgeries [7].

In 1969, Viñas [8] presented his technique of frontal facelift, by using a prehairy and intrahairy treatment (front bone); cutting the skin and the galea in both cases and inverting the flap for a better treatment of the frontal and corrugator muscles. In 1981, Coiffman [9] published a technique for treating the forehead and eyelid wrinkles. He recommended, besides other aspects, drying up the eyelid muscles. Then, he stopped this technique since it left an eyelid depression over time. There exist a lot and very important contributions of surgeons such as Regnault Kaye, Pitanguy, Riefkohl, Owsley, Adamson, Papillon, Connell, McKinney, Matarasso, Terino, Psillakis, Hinderer, and many others, who presented innovative techniques always looking for the perfection of the face higher third part [10].

In the last decade of the twentieth century, Isse, Ramírez, Vasconez, and Chajchir disclosed their first experiences of forehead-lift by means of small incisions and use of the endoscope. These techniques revolutionized the surgical practices of the aesthetic surgery, but controversies were presented later on since there were those who defended the traditional surgery with the argument that where there was skin excess, it was necessary to remove it and reposition the loosened tissues, whereas others continued to prefer the endoscopic surgery.

45.3 Forehead Anatomy

Knowledge of the forehead’s complex anatomy gives us the basis for choosing a good surgical technique according to each patient’s situation.

We can consider the frontal region as an aesthetic subunit limited in the higher and lateral part by the hairline and in the lower part by the eyebrows. When making the incisions, the lines of less skin tension should be kept in mind. In the facial higher third part, the following structures are found: (1) The skin and the subcutaneous cellular tissue. (2) The superficial aponeurotic muscle determined by the eyelid’s orbicular muscle, the frontal muscle, and the occipital muscle joint by the epicranial aponeurosis or aponeurotic galea. (3) The deep muscular system including the superciliary depressor muscle, the nose proceruspyramidal muscle, and the corrugator muscle. (4) The vascular–nervous system formed by the supratrochlear vascular–nerve package, supraorbital vascular–nerve

package, and the periosteum. (5) The retaining ligaments where we find the higher septum-temporal, lower septum-temporal, and the periorbital septum.

(6) The motor innervation of the frontal region and the scalp depending on the facial nerve [11] (Fig. 45.1).

45.4 Ciliary Ptosis Classification

It is important to evaluate the eyelid position to be able to provide the best treatment since this influences the forehead and eyelids. The eyebrows have a head, body, and tail. We can see the following characteristics in the eyebrows:

Normal (Fig. 45.2): The eyebrows should go on the orbital edge in young people. The ideal eyebrow is limited by taking an imaginary line that passes by the internal border of the eye, extending it up to the nasal base, an oblique line drawn from the nasal base up to the orbital edge, another line that unites the higher points of the lines previously described, a parallel line to the first one that passes through the external edge of the ocular iris and finally, one that joins the intersection of the first one with the third one extending it up to the external border, giving us the ideal eyebrow limits.

Eyebrow Ptosis, Medial Position: The eyebrow is seen fallen in its central part (Fig. 45.3).

Eyebrow Ptosis: The eyebrow is seen fallen. It is lower than the orbital edge and the swollen eyelids, giving an aspect of tired and bored person (Fig. 45.3).

Lateral Ptosis: Observed is a decrease of the eyebrow tail with increase of the crow’s-feet wrinkles (Fig. 45.3).

45.5Nonsurgical Techniques in Forehead Rejuvenation

Botulinum Toxin: It is the capacity of the botulinum toxin type A to produce muscle paralysis for cosmetic purposes that occurs by inhibiting the muscle movement of the corrugator, procerus, and frontal muscles. This has a duration of 3 to 6 months. It is used in patients that do not want surgery [12].

Soft Tissue Filling: There exist in the market a number of products to fill forehead and eyebrow